Print Form
Health History
Patient:
Physician's Name
Date of last visit
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of lonimin, adipex, Fastin (brand names of phentemine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
Yes
No
Are you currently taking Fosamax?.
Yes
No
Please select "yes" or "no" to indicate if you have had any of the following?
AIDS/HIV
Yes
No
Anemia
Yes
No
Arthritis, Rheumatism
Yes
No
Artificial Hearth Valves
Yes
No
Artificial Joints
Yes
No
Asthma
Yes
No
Back Problems
Yes
No
Bleeding abnormally,
with extractions or surgery
Yes
No
Blood Disease
Yes
No
Cancer
Yes
No
Chemical Dependency
Yes
No
Chemotherapy
Yes
No
Circulatory Problems
Yes
No
Congenital Hearth Lesions
Yes
No
Cortisone Treatments
Yes
No
Cough, persistent or bloody
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Do you wear contact lenses
Yes
No
Epilepsy
Yes
No
Fainting or Dizziness
Yes
No
Glaucoma
Yes
No
Headaches
Yes
No
Heart Murmur
Yes
No
Heart Problems
Yes
No
Hepatitis Type
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Jaundice
Yes
No
Jaw Pain
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Mitral Valve Prolapse
Yes
No
Nervous
Yes
No
Pacemaker
Yes
No
Psychiatric Care
Yes
No
Radiation Treatment
Yes
No
Respiratory Disease
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
Shortness of Breath
Yes
No
Sinus Trouble
Yes
No
Skin Rash
Yes
No
Special Diet
Yes
No
Stroke
Yes
No
Swolen Feet or Ankles
Yes
No
Swollen Neck Glands
Yes
No
Thyroid Problems
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumor or growth in head or neck
Yes
No
Ulcer
Yes
No
Venereal Disease
Yes
No
Weight Loss, unexplained
Yes
No
Women
Are you pregnant?
Yes
No
Taking birth control pills?
Yes
No
Due Date
Are you nursing?
Yes
No
Medications
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name
Phone
Allergies
Aspirin
Barbiturates (Sleeping pills)
Codeine
Iodine
Latex
Local Anesthetic
Penecillin
Sulfa
Other
Updates
(To be filled out in future appointments)
Has there been any change in your health since your last dental appointment?
Yes
No
For what conditions?
Are you taking any new medications?
If so, what?
Patient's Signature
Date
Doctor's Signature
Date
Has there been any change in your health since your last dental appointment?
Yes
No
For what conditions?
Are you taking any new medications?
If so, what?
Patient's Signature
Date
Doctor's Signature
Date
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